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Persistent Group B streptococcus bacteremia without clinical “sepsis” in infants
LETTERS TO T H E E D I T O R Clinical notes
"Clinical Notes" represent clinical and/or laboratory experiences which can be presented in 200 to 100 words, 3 or 4 references, and, if contributory, one illustration or short table, "Clinical Notes" are subject to tim same critical peer review and editing as papers published in other sections of the JOURNAl_.
Persistent Group B Streptococcus bacteremia without clinical "'sepsis'" in infants To the Editor: The Group B Streptococcus (GBS) is recognized as a cause o f fulminant pneumonia (early-onset GBS) and meningitis in newborn infants (late-onset GBS). I Howard and McCracken 2 have described a clinical spectrum of GBS infections, including four neonates with "asymptomatic" bacteremia. To this experience we would like to add the following two cases. CASE REPORTS Case 1. Patient N. R. was brought to a physician at 14 days o f age because o f a crusted, 1/2 to 1 cm scalp lesion. The lesion was considered related to fetal monitoring with a scalp electrode. Purulent material containing gram-positive cocci on smear was expressed and a small incision was considered to effect complete drainage. Cultures of the lesion and of the blood were obtained and the child was sent home to receive local care with pHisoHex. The following day the child was noted to have residual local infection without systemic signs of illness. Cultures were repeated and local care was again advised. The following day organisms were detected in the original blood sample. A full evaluation for sepsis was undertaken, a n d antibiotics were administered intravenously. GBS was recovered from cultures of blood, nose, umbilicus, and urine obtained on the day of admission and the preceding day; cerebrospinal fluid was sterile. Staphylococcus aureus was isolated from the abscess. At no time was the child febrile nor was there evidence of poor feeding, vomiting, lethargy, or irritability. Case 2. Patient D. S. was brought to a physician at four days o f age because o f a purulent eye discharge. Examination revealed no additional abnormalities and sodium sulfacetamide was pfe-'scribed. The mother administered the drug for 10 days but noted little improvement. Three days later she felt the eyelids appeared more swollen. Examination again revealed conjunctivitis as the only abnormality; chloramphenicol eye drops were prescribed, and a blood culture was obtained. White blood cell count was 11,000imm 3 with a normal differential count. The following
day the child was thriving and had gained weight. Because of concern about the continued drainage from the eye, however, an additional blood culture was obtained. The next day, GBS was identified in both blood cultures; cerebrospinal fluid was obtained and proved to be bacteriologically sterile. The child was treated intravenously with penicillin an d topically with chloramphenicol eye drops; he remained afebrile throughout the hospital course, fed well, and was normally active. DISCUSSION The neonates with asymptomatic bacteremia in Howard and McCracken's ~ report were cultured shortly after birth and observed without treatment until th e laboratory reported the presence of GBS in the blood. It is not clear from the report whether all four had "spontaneous" resolution of bacteremia or if the bacteremia persisted. The presence o f sepsis with minimal clinical findings is not unexpected in the neonatal period, but the two infants in this report demonstrate the possibility of persistent bacteremia over 24 to 48 hours without treatment and without clinical signs usually expected with prolonged septicemia. In neither infant did the superficial "focus" yield GBS: in one, Staphylococcus aureus was incriminated as the cause of the small abscess; in the other no organism was identified. In both infants bacteremia was unexpected. As a result of studies relating fever and bacteremia in infants, 3 the distinction between septicemia and "simple" bacteremia has been noted, though most authors prefer to ignore the semantic distinction and to treat potentially life-threatening illness. 4 With GBS in young infants this view seems particularly justified since the pathogenesis of"late-onset" meningit!s is unknown at present and an asymptomatic early bacteremia might well be involved. How much longer than 24 hours the untreated GBS bacteremia might have persisted in our patients without resolution of body defenses, development o f focal disease (such as meningitis, osteornyelitis, etc.), or appearance of clinical "sepsis" is unknown. Kenneth B. Roberts, M.D. Department of Pediatrics The Johns Hopkins Hospital 601 North Broqdway Baltimore, Mcl. 21205
TheJourna!ofPEDIATRICS Vol. 88, No. 6, pp. 1059-1073
1059
1060
Letters to the Editor
REFERENCES
1. McCracken G: Group B streptococci: the new challenge in neonatal infections, J PEOIAXR 82:703, 1973. 2: Howard J, and McCracken G: The spectrum of group B streptococcal infections in infancy, Am J Dis Child 128:815, 1974. 3. McGowan JE Jr, et al: Bacteremia in febrile children seen in a "walk-in" pediatric clinic, N Engl J Med 288:1309, 1973. 4. Smith A: Childhood bacteremia, N Engl J Med 288:1351, 1973.
The Journal of Pediatrics June 1976
34 patients and Powers and Boisvert ~ in a series in excess of 100 patients did not report isolation o f any anaerobic organisms. In reviewing the microbiological data for all anaerobic isolates at the Massachusetts General Hospital, Bornstein and associates 4 noted that the only anaerobic pathogen causing upper respiratory tract infections was Bacteroides. However, we have been unable to find a previous report of isolation of Bacteroides from cervical adenitis. With improved methods of anaerobic isolation in the bacteriology laboratory, and an increased recognition of the importance of routine anaerobic cultures of cervical adenitis, more anaerobes will undoubtedly be recovered.
Bradley J. Bradford, M.D. Resident Georgetown University Medical Center Department of Pediatrics Washington, D. C. Stanley A. Plotkin, M.D. Children's Hospital of Philadelphia 34 Civic Center Blvd. Philadelphia, Pa. 19104
Cervical adenitis caused by anaerobic bacteria To the Editor: The subject of cervical adenitis in childhood was recently reviewed in THE JOURNAL by Barton and Feiginr who point out the necessity for anaerobic as well as aerobic cultures in evaluating the bacterial etiology of these infections. This report is intended to substantiate their contention with specific reference to two children with cervical adenitis from whom anaerobic organisms were cultured by using modern techniques. CASE REPORTS Case 1. Patient D. O. was a five-year-old Puerto Rican male admitted with a three-day history of an earache, associated with fever and cervical swelling. On admission his temperature was 39~ and the left cervical area was red and swollen with a 4 by 2 cm tender mass. The white blood count was 14,400/mm 3 with 76% polymorphonuclear leukocytes, 11% band forms, 11% lymphocytes, and 2% atypical lymphocytes. Aspiration o f the mass revealed purulent material, the cultures of which grew two organisms (both penicillin sensitive) an alpha hemolytic viridans Streptococcus and a Bacteriodes species. The patient received a seven-day course of intravenous penicillin and recovered uneventfully. Case 2. Patient L. S. a 16-year-old female, was admitted with a right cervical mass of two months' duration. Temperature was 39~ On physical examination the tonsils were red with obvious exudate; the neck had a right 3 by 2 cm submandibular mass and left 1 by 1 cm mass in the strenocleidomastoid area. The admission white blood count was 4,700/mm ~ with 60% segmented forms and 40% lymphocytes. The area was surgically drained, and a culture of the recovered purulent material grew peptostreptococcus and a Bacteroides species. The organisms were sensitive to penicillin and the patient received two weeks of intravenous penicillin therapy. Recovery was complete. DISCUSSION Cervical adenitis is a fairly common entity in the pediatric age group as a sequel of pharyngotonsillar infections. The two cases reported here are examples of anaerobic organ!sms as the cause of bacterial adenitis which finding seems unusual as a survey of the literature demonstrated. Dajani and associates, ~ in a series Of
REFERENCES
1. Barton L, and Feigin R: Childhood cervical lymphadenitis, A reappraisal, J PEDIATR 84:846, 1974. 2. Dajani AS, Garcia R, and Wolinsky E: Etiology of cervical adenitis in children, N Engl J Med 268:1329, 1965. 3. Powers G, and Boisvert P: Age in streptococcocis, J PEDIATR 25:481, 1944. 4. Bornstein DL, Weinberg A, Swartz M, and Kunz L: Anaerobic infections: Review of current experience, Medicine 43:207, 1964.
IgA deficiency and recurrent pneumonia in the Schwartz-Jampel syndrome To the Editor: A girl with the Schwartz-Jampel syndrome (myotonia, blepharophimosis, and joint limitation 1) and repeated infections had a selective deficiency of IgA in serum and external secretions. CASE REPORT Patient A. R., 3% years of age, had a stiff gait and recurrent pneumonias. She was below the third percentile for both height (82 cm) and weight (9.3 kg) and displayed (Fig. 1) hypertelorism , blepharophimosis, decreased lid fissure length (18 ram), bilateral ptosis, pursed lips, a hypoplastic mandible, and severe dental caries. A kyphotic thorax with pectus carinatum supported an elevated shoulder girdle, which was contracted with a restricted
From the LaRabida Children's Hospital and Research Center, University of Chicago.
"Clinical Notes" represent clinical and/or laboratory experiences which can be presented in 200 to 100 words, 3 or 4 references, and, if contributory, one illustration or short table, "Clinical Notes" are subject to tim same critical peer review and editing as papers published in other sections of the JOURNAl_.
Persistent Group B Streptococcus bacteremia without clinical "'sepsis'" in infants To the Editor: The Group B Streptococcus (GBS) is recognized as a cause o f fulminant pneumonia (early-onset GBS) and meningitis in newborn infants (late-onset GBS). I Howard and McCracken 2 have described a clinical spectrum of GBS infections, including four neonates with "asymptomatic" bacteremia. To this experience we would like to add the following two cases. CASE REPORTS Case 1. Patient N. R. was brought to a physician at 14 days o f age because o f a crusted, 1/2 to 1 cm scalp lesion. The lesion was considered related to fetal monitoring with a scalp electrode. Purulent material containing gram-positive cocci on smear was expressed and a small incision was considered to effect complete drainage. Cultures of the lesion and of the blood were obtained and the child was sent home to receive local care with pHisoHex. The following day the child was noted to have residual local infection without systemic signs of illness. Cultures were repeated and local care was again advised. The following day organisms were detected in the original blood sample. A full evaluation for sepsis was undertaken, a n d antibiotics were administered intravenously. GBS was recovered from cultures of blood, nose, umbilicus, and urine obtained on the day of admission and the preceding day; cerebrospinal fluid was sterile. Staphylococcus aureus was isolated from the abscess. At no time was the child febrile nor was there evidence of poor feeding, vomiting, lethargy, or irritability. Case 2. Patient D. S. was brought to a physician at four days o f age because o f a purulent eye discharge. Examination revealed no additional abnormalities and sodium sulfacetamide was pfe-'scribed. The mother administered the drug for 10 days but noted little improvement. Three days later she felt the eyelids appeared more swollen. Examination again revealed conjunctivitis as the only abnormality; chloramphenicol eye drops were prescribed, and a blood culture was obtained. White blood cell count was 11,000imm 3 with a normal differential count. The following
day the child was thriving and had gained weight. Because of concern about the continued drainage from the eye, however, an additional blood culture was obtained. The next day, GBS was identified in both blood cultures; cerebrospinal fluid was obtained and proved to be bacteriologically sterile. The child was treated intravenously with penicillin an d topically with chloramphenicol eye drops; he remained afebrile throughout the hospital course, fed well, and was normally active. DISCUSSION The neonates with asymptomatic bacteremia in Howard and McCracken's ~ report were cultured shortly after birth and observed without treatment until th e laboratory reported the presence of GBS in the blood. It is not clear from the report whether all four had "spontaneous" resolution of bacteremia or if the bacteremia persisted. The presence o f sepsis with minimal clinical findings is not unexpected in the neonatal period, but the two infants in this report demonstrate the possibility of persistent bacteremia over 24 to 48 hours without treatment and without clinical signs usually expected with prolonged septicemia. In neither infant did the superficial "focus" yield GBS: in one, Staphylococcus aureus was incriminated as the cause of the small abscess; in the other no organism was identified. In both infants bacteremia was unexpected. As a result of studies relating fever and bacteremia in infants, 3 the distinction between septicemia and "simple" bacteremia has been noted, though most authors prefer to ignore the semantic distinction and to treat potentially life-threatening illness. 4 With GBS in young infants this view seems particularly justified since the pathogenesis of"late-onset" meningit!s is unknown at present and an asymptomatic early bacteremia might well be involved. How much longer than 24 hours the untreated GBS bacteremia might have persisted in our patients without resolution of body defenses, development o f focal disease (such as meningitis, osteornyelitis, etc.), or appearance of clinical "sepsis" is unknown. Kenneth B. Roberts, M.D. Department of Pediatrics The Johns Hopkins Hospital 601 North Broqdway Baltimore, Mcl. 21205
TheJourna!ofPEDIATRICS Vol. 88, No. 6, pp. 1059-1073
1059
1060
Letters to the Editor
REFERENCES
1. McCracken G: Group B streptococci: the new challenge in neonatal infections, J PEOIAXR 82:703, 1973. 2: Howard J, and McCracken G: The spectrum of group B streptococcal infections in infancy, Am J Dis Child 128:815, 1974. 3. McGowan JE Jr, et al: Bacteremia in febrile children seen in a "walk-in" pediatric clinic, N Engl J Med 288:1309, 1973. 4. Smith A: Childhood bacteremia, N Engl J Med 288:1351, 1973.
The Journal of Pediatrics June 1976
34 patients and Powers and Boisvert ~ in a series in excess of 100 patients did not report isolation o f any anaerobic organisms. In reviewing the microbiological data for all anaerobic isolates at the Massachusetts General Hospital, Bornstein and associates 4 noted that the only anaerobic pathogen causing upper respiratory tract infections was Bacteroides. However, we have been unable to find a previous report of isolation of Bacteroides from cervical adenitis. With improved methods of anaerobic isolation in the bacteriology laboratory, and an increased recognition of the importance of routine anaerobic cultures of cervical adenitis, more anaerobes will undoubtedly be recovered.
Bradley J. Bradford, M.D. Resident Georgetown University Medical Center Department of Pediatrics Washington, D. C. Stanley A. Plotkin, M.D. Children's Hospital of Philadelphia 34 Civic Center Blvd. Philadelphia, Pa. 19104
Cervical adenitis caused by anaerobic bacteria To the Editor: The subject of cervical adenitis in childhood was recently reviewed in THE JOURNAL by Barton and Feiginr who point out the necessity for anaerobic as well as aerobic cultures in evaluating the bacterial etiology of these infections. This report is intended to substantiate their contention with specific reference to two children with cervical adenitis from whom anaerobic organisms were cultured by using modern techniques. CASE REPORTS Case 1. Patient D. O. was a five-year-old Puerto Rican male admitted with a three-day history of an earache, associated with fever and cervical swelling. On admission his temperature was 39~ and the left cervical area was red and swollen with a 4 by 2 cm tender mass. The white blood count was 14,400/mm 3 with 76% polymorphonuclear leukocytes, 11% band forms, 11% lymphocytes, and 2% atypical lymphocytes. Aspiration o f the mass revealed purulent material, the cultures of which grew two organisms (both penicillin sensitive) an alpha hemolytic viridans Streptococcus and a Bacteriodes species. The patient received a seven-day course of intravenous penicillin and recovered uneventfully. Case 2. Patient L. S. a 16-year-old female, was admitted with a right cervical mass of two months' duration. Temperature was 39~ On physical examination the tonsils were red with obvious exudate; the neck had a right 3 by 2 cm submandibular mass and left 1 by 1 cm mass in the strenocleidomastoid area. The admission white blood count was 4,700/mm ~ with 60% segmented forms and 40% lymphocytes. The area was surgically drained, and a culture of the recovered purulent material grew peptostreptococcus and a Bacteroides species. The organisms were sensitive to penicillin and the patient received two weeks of intravenous penicillin therapy. Recovery was complete. DISCUSSION Cervical adenitis is a fairly common entity in the pediatric age group as a sequel of pharyngotonsillar infections. The two cases reported here are examples of anaerobic organ!sms as the cause of bacterial adenitis which finding seems unusual as a survey of the literature demonstrated. Dajani and associates, ~ in a series Of
REFERENCES
1. Barton L, and Feigin R: Childhood cervical lymphadenitis, A reappraisal, J PEDIATR 84:846, 1974. 2. Dajani AS, Garcia R, and Wolinsky E: Etiology of cervical adenitis in children, N Engl J Med 268:1329, 1965. 3. Powers G, and Boisvert P: Age in streptococcocis, J PEDIATR 25:481, 1944. 4. Bornstein DL, Weinberg A, Swartz M, and Kunz L: Anaerobic infections: Review of current experience, Medicine 43:207, 1964.
IgA deficiency and recurrent pneumonia in the Schwartz-Jampel syndrome To the Editor: A girl with the Schwartz-Jampel syndrome (myotonia, blepharophimosis, and joint limitation 1) and repeated infections had a selective deficiency of IgA in serum and external secretions. CASE REPORT Patient A. R., 3% years of age, had a stiff gait and recurrent pneumonias. She was below the third percentile for both height (82 cm) and weight (9.3 kg) and displayed (Fig. 1) hypertelorism , blepharophimosis, decreased lid fissure length (18 ram), bilateral ptosis, pursed lips, a hypoplastic mandible, and severe dental caries. A kyphotic thorax with pectus carinatum supported an elevated shoulder girdle, which was contracted with a restricted
From the LaRabida Children's Hospital and Research Center, University of Chicago.